Rural-Urban Differentials in Access to Behaviour Change Communication and Use of Long-Lasting Insecticide-Treated Nets and Artemisinin-Based Combination Therapy in Southeast Nigeria

Background As Malaria continues to take a heavy toll on the life and economy of Nigerians, The National Malaria Elimination Programme uses behaviour change communication (BCC) to promote the use of Long-Lasting Insecticide-treated Nets (LLIN) and Artemisinin-based Combination Therapy (ACT) to combat malaria. This study examined the impact of BCC on the use of LLIN and ACT in Southeast Nigeria. Methods A structured questionnaire was used to gather data from 480 respondents in urban and rural communities across five states. Analysis of data was done using percentages, chi-square and logistic regression. Results Findings showed weak effect of BCC on LLIN and ACT use despite achieving high (93.75%) exposure. Only 45.1% and 45.7% of the respondents used LLIN and ACT respectively. Urban residents were found to sleep under LLINs and use ACTs more than rural dwellers. Regression results showed that newspapers (OR=1.341) and the Internet (OR=3.216) increased the odds of LLIN use in the rural areas and magazines (OR=1.837) in the urban areas. Television (OR=2.375; P=0.002) and the Internet (OR=6.063; P=0.001) increased the odds of ACT use in the urban areas. Education was found to be a positive predictor of LLIN use in the rural (OR=4.645; P=0.011) and urban areas (OR=6.102) as well as ACT use in the rural (OR=7.268; p=0.002) and urban areas (0R=6.145; P=0.009). Conclusion Access to behaviour change communication though very high has not achieved the desired behaviour change. The National Malaria Elimination Programme should produce appropriate messages to address barriers to LLIN and ACT use.


INTRODUCTION
Nigeria is the most malaria endemic country in the world, accounting for 27% and 24% of global malaria morbidity and mortality respectively (1). In addition, malaria costs Nigeria ₦132 Billion in annual economic loss (2). The National Malaria Elimination Programme (NMEP) employs behaviour change communication extensively to persuade Nigerians to sleep under Long Lasting Insecticide-treated Nets (LLINs) and treat malaria with Artemisinin-based Combination Therapy (ACTs) as LLINs and ACTs have been proven efficacious in malaria control.
Studies have shown that exposure to behaviour change communication (BCC) is a positive predictor of LLIN use (3,4,5), and effective in raising public awareness and knowledge of malaria (6,7,8,9,10). This is important because misconceptions about the cause of malaria often result in rejection of promoted malaria control measures (9,11,12) However, there are other variables such as place of residence that affect use of nets. For instance, some studies (13,14,15) found higher ownership of ITNs in rural areas than urban areas. This might be as a result of the fact many nations direct a lot of attention to rural areas in free ITN distribution campaigns. Rural areas suffer from infrastructural deficit, particularly in developing countries (16). However, other studies indicate higher ownership and use of ITNs in urban areas (17,18).
Moreover, higher education has been found to be a predictor of LLIN use (19,15,20). One explanation for the readiness of educated people to use LLINs may be that they are less likely to have misconceptions about malaria. Such misconceptions include beliefs that the chemicals in the LLINs would kill unborn children, cause chronic diseases and even sterility (21)(22)(23). Complaints of discomfort are in the form of excessive heat and feelings of suffocation associated with net use (24)(25)(26). Furthermore, socioeconomic status can also affect adoption of LLIN. Those in the upper socioeconomic quintiles have been reported to be more likely to sleep under nets (27)(28)(29)(30) Whenever malaria prevention fails, attention turns to treatment. Both the World Health Organisation (WHO) and NMEP favour Artemisinin-based combination therapy for malaria treatment (31,32). However, studies have indicated low utilization of ACTs in many places (33)(34)(35)(36). The poor utilization of ACT may be traced to competing treatment regimens employed by people. For instance, some studies (37,38,33) have found high reliance on herbs for malaria treatment among their study populations. Even where people use drugs, the tendency in many places has been to "mix drugs" (39,38) which is the act of combining doses of different drugs for malaria treatment, a practice that is discouraged in the malaria control media campaigns.
Many studies have focused on the impact of BCC on the use of insecticide-treated nets, but there is a dearth in studies that examine both the use of nets and ACTs (32). This study seeks to fill the gap by examining the extent to which Southeast Nigeria residents were exposed to behaviour change communication on malaria and how it has influenced use of LLINs and ACTs for malaria control.

METHODS
The study was a survey of 15 rural and urban communities across the five states that make up the Southeast geo-political region of Nigeria which include Abia, Anambra, Ebonyi, Enugu and Imo states. The study made use of 480 respondents. The sample size was derived from the population of the five states using the Wimmer and Dominick Online sample size calculator.
Data were collected by means of a structured questionnaire containing both open-ended and closed-ended questions. Two dependent/outcome variables were used in the study. These were the use of long-lasting insecticide-treated nets (LLINs) and Artemisinin Combination Therapy (ACT). The respondents were asked if they slept under LLINs the night preceding the survey, and if they used ACT for malaria treatment. For each of the outcome variables, their responses were categorized into 1=yes if they use any of LLIN or ACT and 0= no if they did not use any of LLIN or ACT.
The major independent variable used in the study was exposure to mass media messages on malaria through media channels such as television, radio, magazines, newspapers, the internet and billboards. Respondents who were exposed to each channel were coded 1 (yes) while respondents not exposed to any particular media channel were coded 0 (no). Furthermore, the study made use of individual-level explanatory variables such as gender (male/female), age (less than 30, 30-49, 50+years), education (none/primary, secondary, tertiary), marital status (never married, married, widowed/divorced), employment status (unemployed/student, farmer/businessman, civil servant), income level (up to N20,000, N21,000-N50,000, more than N50,000).
The data were analyzsed by means of the Statistical Package for the Social Sciences (SPSS). Percentages were used to describe the study population and exposure to malaria messages by respondents. Percentages were also used to describe the use of insecticide-treated nets and ACT. The results of these descriptive analyses were presented in tables. Finally, logistic regression was used to estimate the factors that predict use of insecticide-treated nets and Artemisinin combination therapy among the study population. The regression coefficients of the independent variables are expressed as Odds Ratio (OR). With respect to the coefficients, a variable with Odds Ratio greater than 1.00 indicated that the variable increases the likelihood of ITN/ACT use while a decreased likelihood of ITN/ACT use is implied where the Odds Ratio is less than 1.00. Four regression models were generated for the study. Model 1 shows the use of ITNs in rural areas while Model 2 shows the use of ITNs in urban areas. Model 3 and Model 4 show the use of ACT in rural and urban areas respectively.

RESULTS
A total of 450 (93.75%) of the respondents reported having been exposed to mass media messages on malaria. Specifically, 93.18% and 94.88% of urban and rural respondents respectively reported being exposed to the media messages. Radio and television were the dominant sources of information on malaria with 79.2% of the respondents reporting having been exposed to the messages via radio and 51.9% through television. Out of the 450 (93.75%) respondents exposed to media messages, 402(89.3%) reported owning at least one LLIN. However, 203(45.1%) reported sleeping under LLINs the night preceding the survey. This comprised 46.74% of urban and 38.03% rural respondents.
Furthermore, 206 (45.7%) respondents reported using ACTs for malaria treatment. This comprised 51.91% and 32.56% of urban and rural respondents respectively. Many respondents reported treating malaria with herbal medicine, non-ACT drugs and mixed drugs. Regression analyses were further used to underscore the magnitude of the impact of mass media messages and the demographic variables on the use of LLINs and ACTs.  Table 3: Regression results of socio-economic predictors of LLIN and ACT use.

Model4(ACT) Urban Gender
Male (RC) Female  Table 3 shows regression results of socioeconomic predictors of net and ACT use in the rural and urban areas. Data in model 1 indicate that marital status, education, higher socioeconomic status, being civil servants and farmers increased the odds of net use in the rural areas. For instance, Females were found to be 1.5 times (OR=1.545) likely to sleep under the net relative to males. Those with tertiary education (OR=4.645; P=0.011); and residents of Anambra (OR-8.425; P=0.001); Imo (OR=10.684; P=0.001) and Ebonyi (OR=12.678; P=0.000) were significantly likely to sleep under nets. In the urban areas (model 2), the divorced/widowed, the educated, civil servants and residents of Anambra and Ebonyi states had increased odds of sleeping under nets. Model 3 shows that secondary education (OR=2.951) and tertiary education (OR=7.268; P=0.002) increased the likelihood of ACT use in the rural areas. In addition, data show that rural residents of Anambra, Imo, Ebonyi and Abia states were significantly likely to use ACT relative to residents of Enugu. Among urban dwellers, model 4 indicates that those with tertiary education (OR=6.145; P=0.009) had significantly increased odds of using ACT for malaria treatment. In addition, divorced/widowed people, farmers/businessmen, civil servants and those with higher income were associated with increased odds of ACT use in the urban areas. Table 4 shows the regression results of the combined effects of mass media and socioeconomic variables on net and ACT use. Data in model 1 show that while television significantly decreased the odds of net use among rural dwellers, newspapers, magazines and the internet increased the odds. In addition, tertiary education (OR=5.005; P=0.018); higher income, being farmers/businessmen positively predicted use of nets in the rural areas. In the urban areas, model 2 shows that all mass media negatively predicted net use except the magazine and internet. The married, divorced/widowed and tertiary education (OR=7.574; P=0.009) were correlated with increased odds of net use among urban dwellers. Model 3 in Table 4 further shows the combined effects of mass media and socioeconomic characteristics on ACT use in the rural areas. As can be observed, access to radio (OR=2.078) increased by 2.07 times the odds of using ACT in the rural areas compared to television (OR=2.375); and the Internet (OR=3.505). Tertiary education (OR=6.921; p<0.006), being residents of Anambra state (OR=5.979; p<0.012); Imo state (OR=8.577; p<007), Ebonyi state (5.334; p<0.019) and Abia state (OR=3.446;p<0.019) all significantly predicted increased likelihood of ACT use for malaria treatment in the rural areas.
In the urban areas, as shown in model 2 only access to billboard messages (2.888; p<0.011) and tertiary education increased the odds of ACT use.

DISCUSSION
There was high exposure to behaviour change communication on malaria prevention in